Decreasing popularity of e-cigarettes could 'open the floodgates' for smoking alternative heat-not-burn tobacco

A smoking trend that’s taken over Japan could soon be making its debut in the American market, possibly eclipsing e-cigarettes as a “more authentic” alternative to traditional tobacco products.

Heat-not-burn cigarettes are battery-powered devices that take tobacco to the brink of combustion by heating tobacco leaves to around 500 degrees and producing an inhalable aerosol, researcher Theodore L. Caputi and colleagues wrote in a recent PLOS One-published study. The smoking alternative has exploded in Japan, where average monthly searches for heat-not-burn tobacco products rose 1,426 percent between 2015 and 2016, but clinicians are largely unaware of its cardiovascular risks.

“We do not know the health implications of heat-not-burn tobacco,” Caputi said in an email. “While they are likely to be marketed—formally or informally—as ‘healthier’ than cigarettes, there is insufficient evidence to make that claim. In itself, insufficient evidence is dangerous—tobacco companies have proven they won’t wait until all the facts are in before they begin making health claims, and public health researchers need to fill in knowledge gaps quickly so that consumers can make well-informed decisions.”

Because of the public health implications of tobacco use, Caputi said, including the fact that nearly half of all smokers are estimated to die from a smoking-related illness, “this is not a decision that consumers should take lightly.”

In his study, Caputi and four colleagues used Google search query data to analyze the rising popularity of heat-not-burn products. Because traditional surveys about smoking don’t ask about heat-not-burn tobacco, and since the product has little visibility in U.S. markets, the researchers focused on search engine analysis to evaluate the scale and growth potential of the new trend.

In Japan, they found, there are now between 5.9 and 7.5 million estimated heat-not-burn-related Google searches per month, based on estimates from September. After initial heat-not-burn products hit the Japanese market in 2015, spurring a nearly 1,500 percent peak in Google searches on the topic, related searches grew by an additional 100 percent during the next year.

Caputi and colleagues compared search queries for heat-not-burn products in Japan to Google searches for e-cigarettes in the U.S., since e-cigarettes aren’t legal in Japan. Heat-not-burn searches occurred more frequently in Japan than e-cigarette searches did in the U.S., the authors reported, with the first queries for heat-not-burn cigarettes eclipsing e-cigarettes in April 2016.

The popularity of e-cigarettes in the U.S. is waning, Caputi said in a September 2016 article published in the medical journal Tobacco Control. Whereas growth of the e-cig industry was predicted to rise 126 percent in 2016, new Euromonitor International statistics estimate the reality to be closer to 51 percent.

E-cigarette users are becoming displeased with the taste of the product, he said, citing Wells Fargo tobacco analyst Bonnie Herzog. While consumers aren’t necessarily concerned with the health risks of the product, they notice a lag in gratification from e-cigarettes that isn’t true for traditional cigarettes, which deliver nicotine to the bloodstream much more quickly. E-cigarettes also lack a “throat hit,” Caputi wrote, which many conventional tobacco users enjoy. Heat-not-burn products offer those feelings that e-cigarettes lack.

“The pervasiveness of e-cigarettes and spreading discontentment with the lack of a throat-hit may open the floodgate for heat-not-burn’s success,” he wrote.

Heat-not-burn cigarettes have been gradually introduced to an international market in more than 20 nations, including the United Kingdom, Russia, Korea, Switzerland and Italy, but the focal test market is Japan, Caputi and colleagues wrote in the PLOS One study. Japan Tobacco introduced its local heat-not-burn device, called Ploom TECH, in March 2016, and Philip Morris International’s “IQOS” (“I Quit Ordinary Smoking”) and British American Tobacco’s “Glo” followed soon after.

Now, PMI has entered the FDA approval process to start marketing and sales in the U.S.

According to the Tobacco Control article, a Wells Fargo analyst predicted heat-not-burn products could displace up to 30 percent of the country’s combustible cigarette industry by 2025.

Caputi wrote recent research has suggested heat-not-burn products are less harmful than combustible cigarettes, but other studies have shown risks of smoking heat-not-burn tobacco include carbon monoxide and formaldehyde exposure, as well as the potential for side-stream emissions.

Reto Auer, MD, MAS, and colleagues found that PMI’s IQOS releases smoke containing elements from pyrolysis and thermogenic degradation that mirror the components of traditional cigarette smoke.

“PMI claims that IQOS releases no smoke because the tobacco does not combust and the tobacco leaves are only heated, not burned,” Auer and co-authors wrote in a study published in JAMA Internal Medicine. “However, there can be smoke without fire. Dancing around the definition of smoke to avoid indoor smoking bans is unethical.”

Now, Caputi said, is the time to act. In his PLOS One paper, he and co-authors wrote their findings were a “clarion call” for public health practitioners, who should expand heat-not-burn product surveillance, preemptively study the smoking alternative’s risks and benefits and adjust health messaging about tobacco products.

He said that despite the presence of the product overseas, clinicians in the U.S. are largely unaware of the trend and its implications.

“Unfortunately, we have insufficient evidence to make claims regarding the long-term health effects of either e-cigarettes or heat-not-burn devices, and so making comparisons at this point is very difficult,” Caputi told Cardiovascular Business. “However, we know that e-cigarettes are perceived as less harmful than traditional cigarettes, and we imagine heat-not-burn products will be marketed to cultivate that same perception. While it’s too early to tell if heat-not-burn products will overtake e-cigarettes as the new method of smoking, the available evidence suggests heat-not-burn products are poised for explosive growth as they are introduced into new markets."

Cardiovascular Business
Theodore L. Caputi
Theodore L. Caputi
Economics & Health Researcher

My research interests include public health, health innovation, and health care.